Health care

1.Think critically and write an original discussion post. 10 points

• Read and review the case studies and prohibited abbreviations in the module.
• Make up a situation/case study about a documentation error that used a prohibited abbreviation. -300words
• Include the four sections:The Charting MistakeHow It HappenedThe ResultYour Takeaway2 .For this week’s reflection, read this position statement from the National League for Nursing (NLN) on their stance of the unfortunate events that unfolded in Tennessee: NLN Promotes a Just Culture Approach with Health What are your thoughts about ‘’just culture”? What is the responsibility of the organization in preventing medication errors?-300 words

Case Study #1: Missing Documentation
The Charting Mistake
A healthcare worker ordered frequent leg exams for a patient, who was receiving uterine artery embolization, but the
patient’s records showed no evidence of the exams ever being performed.
How It Happened
It’s unclear whether the nurses actually performed the exams, but if they did, they didn’t document them.
The Result
Though the clinician ordered frequent leg exams, the patient claimed they never happened. A massive blood clot
was removed from the patient’s external iliac artery, resulting in nerve damage. The patient sued and won a $1.5
million verdict, in part because the nurses didn’t have the documentation to prove they did the exams as ordered.
Your Takeaway
Document every procedure you do, as well as its results. If you aren’t able to complete an order, record that, too. As
the medical adage goes, “If you didn’t write it down, it didn’t happen.”

5 Real-Life Patient Charting Mistakes

Case Study #2: Copying & Pasting Inaccurate Information
The Charting Mistake
A healthcare worker copied and pasted an incorrect diagnosis in a patient’s chart, which was then used to treat the
patient.
How It Happened
A resident misdiagnosed the patient with adrenal insufficiency and wrote it in the patient’s chart. The consulting and
attending physicians used a feature of the electronic health record (EHR) that allowed them to copy and paste
resident’s notes as their own and reiterated the incorrect diagnosis in their own notes.
The Result
Clinicians relied on the inaccurate assessment when caring for the patient, and the patient was treated with steroids
for adrenal insufficiency, despite not actually having it. The patient then died as a result of the medication error.
Your Takeaway
Avoid copying and pasting old information into new chart entries unless you’ve personally verified that the
information is correct.

5 Real-Life Patient Charting Mistakes

Case Study #3: Documenting in the Wrong Chart
The Charting Mistake
The wrong chart was used to document a patient’s care in the emergency department.
How It Happened
When the ambulance arrived with the patient, the driver told the emergency department clerk the patient’s name.
The clerk pulled up a medical record in the EHR with the same name but didn’t realize the birthdate was wrong.
The Result
By the time the ambulance driver raised questions about the patient’s age on the record, the medical team had
already started drawing labs and running tests based on the wrong patient information. Thankfully, no known harm
came to the patient, but the medical team may have dodged a bullet. Had they given medications, an unknown drug
allergy could have occurred.
Your Takeaway
Double-check that you have the right patient record by verifying both the patient’s name and birthdate. If you aren’t
sure that you have the right patient, stop the care (if possible) and confirm the patient’s identity right away.

5 Real-Life Patient Charting Mistakes

Case Study #4: Not Documenting as Soon as Possible
The Charting Mistake
A healthcare worker didn’t enter a note into the patient’s chart until several days after the visit. The delay meant that
another clinician, who was treating the patient in the meantime, prescribed them a potentially dangerous medication.
How It Happened
After seeing a patient just before lunchtime, the clinician got sidetracked and didn’t record his notes in the patient’s
chart. Four days later, the clinician returned to work after a long weekend and noticed his mistake. He added his
notes but backdated them so they would be associated with the day the patient was seen.
The Result
During the patient’s initial visit, the patient described experiencing symptoms that were possible reactions to a
prescribed medication. Because the first clinician didn’t enter his notes the day the patient was seen, the second
clinician to care for the patient over the long weekend didn’t know about the possible reaction and prescribed the
very same medication.
Your Takeaway
Input the patient data as soon as you can. If life happens and there’s a delay between seeing the patient and
inputting your documentation, follow your organization’s guidelines on changing the reference date in the EHR.
Even if the time you enter the note is hard-coded into the system, associating the note with a previous date of
service may confuse (or even mislead) other clinicians who rely on your notes to decide and administer care.
Starting the note with a quick “Late Entry,” followed by the date and time of the patient contact, can help avoid any
confusion.

5 Real-Life Patient Charting Mistakes

Case Study #5: Inputting Data Incorrectly
The Charting Mistake
A healthcare worker made a mistake when noting the dose of a medication during a patient transfer to a new facility;
this error resulted in the patient receiving a dosage that was 10 times the appropriate amount.
How It Happened
After being treated for congestive heart failure, a patient was transferred to a rehab facility. There, clinicians noted in
the transfer medication list that the patient was receiving 0.625 mg of digoxin daily, but it was a typo: She was
actually supposed to get 0.0625 mg. Even though her home medication list had the correct number, it didn’t list the
unit of measurement for the dose, and the mistake wasn’t caught during medication reconciliation. When the
admitting resident entered the patient’s information into the rehab facility’s EHR, the system wouldn’t allow
milligrams, so they converted the incorrect dose to micrograms. Later, the pharmacist overrode an alert warning the
dose was too high and didn’t verify the correct number with the ordering clinician.
The Result
The RN on duty added 625 mcg daily to the patient’s medication record — the patient should have received just 62
mcg — and noted that the meds were given. After four days of receiving 10 times the appropriate dose, the patient
complained of nausea and her heart rate plummeted into the 30s. Her blood work came back with high levels of
potassium and digoxin. The patient was transferred to a different facility and returned to baseline, but she died six
weeks later from renal failure and cardiomyopathy.
The admitting nurse at the rehab facility later went back and altered the patient’s medical records to make it look like
the medication had never been given at the facility. The patient’s family sued and settled for over $1 million.
Your Takeaway
Before giving a medication, verify the dose with the ordering clinician — especially if it looks wrong — and don’t
bypass warnings in the EHR or ordering system unless you’re absolutely sure the dose is correct. If you do make a
mistake, don’t go back and change medical records to cover it up.

5 Real-Life Patient Charting Mistakes

This single copy is for your personal, non-commercial use only.
For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact CJHP at cjhpedit@cshp.ca
PHARMACY PRACTICE
Prohibited Abbreviations: Seeking to Educate,
Not Enforce
Karen Horon, Kefah Hayek, and Carmel Montgomery
INTRODUCTION
The use of abbreviations in medication orders has been
identified as an underlying cause of serious, even fatal medication errors. The long-standing practice of using order-writing
shortcuts has been found in medication orders and standing
protocols and has even been legitimized in policies.1 The use of
abbreviations in medication orders results in miscommunication,
because staff members responsible for reading, interpreting, and
processing these orders may not recognize or may misconstrue
the abbreviations, which in turn results in misunderstanding of
the intended meaning.2
The link between the use of dangerous abbreviations
and critical incidents was shown by the Commonwealth of
Pennsylvania Patient Safety Authority, which found, upon
review of 103 critical incidents, that 56% involved the use of
dangerous abbreviations and dose expressions (as reported
during a teleconference entitled “Alphabet Soup: Hazardous to
Your Health!” [sponsored by the Institute for Safe Medication
Practices, February 4, 2005]).
The concept of reducing or even eliminating the use of
dangerous abbreviations is not new. For almost 30 years, the
US Institute of Safe Medication Practices (ISMP) has received
a steady stream of reported errors, some of them causing
critical incidents, due to misinterpretation of a handful of
dangerous abbreviations. The ISMP (US), the Institute for Safe
Medication Practices Canada, the National Coordinating
Council for Medication Error Reporting and Prevention, the
Health Quality Council of Alberta, Accreditation Canada, and
the Joint Commission (formerly the Joint Commission on
Accreditation of Healthcare Organizations) have all aimed to
establish safe practices by advocating for prohibition of a short
list of dangerous abbreviations and dose expressions.
Despite widespread advocacy by these key organizations
seeking a reduction in the use of dangerous abbreviations and
dose designations, such use continues. Nursing and pharmacy
staff are often put in the difficult and risky position of processing
294
C J H P – Vol. 65, No. 4 – July–August 2012
orders that contain dangerous abbreviations and dose designations. The alternative to processing such orders is either clarifying each order or refusing to process the orders, both of which
also put patients at risk.
The former Capital Health—Edmonton & Area,
which consisted of 12 acute care hospitals and 1 rehabilitation
hospital, embarked on a patient safety initiative to reduce the
use of dangerous abbreviations and dose designations. At the
time of the initiative, none of the sites were using computerized
physician order entry. Instead of enforcement through
clarification or refusal to process medication or total parenteral
nutrition (TPN) orders that contained dangerous abbreviations
or dose designations, intensive and focused educational
strategies were used to gain compliance. A 75% reduction in
the use of prohibited abbreviations, relative to baseline, was the
established goal.
METHODS
Although no abbreviation in medication orders is acceptable,
7 abbreviations were considered to be the most dangerous,
according to the Joint Commission and ISMP, and were selected
for prohibition in Capital Health—Edmonton & Area (Table
1). In 2004, the Drugs and Therapeutics Committee and the
Medical Advisory Council approved the list for implementation.
A working group was established to develop a policy,
as well as communication and education materials, and to
implement the list of prohibited abbreviations. The working
group consisted of representatives from nursing, pharmacy, and
quality and patient safety, along with a physician champion.
Because enforcement strategies were not considered a safe
option, the following intensive and focused educational
interventions were developed and delivered and/or distributed
between August 1 and September 30, 2005:
• description and rationale for the prohibited abbreviations
initiative
• communication about the initiative to internal and external
health care providers, educators, and students
J C P H – Vol. 65, no 4 – juillet–août 2012
0232_CJHP-July2012:sept.2008.qxd 8/7/12 7:23 AM Page 295
Table 1. Abbreviations Prohibited by Capital Health—Edmonton & Area
Abbreviation
IU
U or u
Intended Meaning
International Unit
Unit
qd or QD
Every day
qod or QOD
Every other day
Zero after decimal 1 mg
point (1.0)
No zero before
decimal dose
(.5 mcg)
Drug name
abbreviations
•
•
•
Misinterpretation
Misread as IV (intravenous)
Read as zero (0) or four (4),
causing a 10-fold overdose
or greater (4U seen as “40”
or 4u seen as “44”)
Mistaken as q.i.d., especially
if the period after the “q”
or the tail of the “q” is
misunderstood as an “i”
Mistaken as “q.d.” (daily) or
“q.i.d.” (4 times daily) if the
“o” is poorly written
Misread as “10 mg” if the
decimal point is not seen
0.5 mcg
Misread as “5 mcg”
Too numerous to list
Too numerous to list
development and distribution of a list of the prohibited
abbreviations and dose designations and the correct terminology to replace prohibited terms
examples of medication abbreviations and why they pose a
risk to patient safety
provision of a tool kit for each patient care area, containing posters (Figure 1), frequently asked questions, stickers
for the bookmark in medical charts (Figure 2 and
described in more detail below), and self-adhesive notes
(Figure 3)
Figure 1. Poster for unit-level display. Poster background
was bright green. See Appendix 1 (available at www.cjhponline.ca/index.php/cjhp/issue/view/88/showToc) for the
colour version of this poster.
©2005-2012 Alberta Health Services
C J H P – Vol. 65, No. 4 – July–August 2012
Correction
Use “unit”
No acceptable abbreviation;
use “unit”
Use “daily” or “every day”
Use “every other day”
Do not use terminal zeros for
doses expressed in whole
numbers
Always use zero before a
decimal when the dose is less
than a whole number
Use the complete spelling
for drug names
•
in-service sessions for medical, pharmacy, and nursing staff
and dietitians
• electronic availability of a PowerPoint presentation
(Microsoft Canada, Mississauga, Ontario) with speaking
notes, for additional education sessions and for self-study
• regular reporting of audit results to all staff, including
medical staff, as well as to the Drugs and Therapeutics
Committee and the Medical Advisory Council
One-time communication to educational facilities took
the form of a memorandum, which included the approved list
of prohibited abbreviations, as well as a suggestion to include a
section on prohibited abbreviations in course work. Letters
cosigned by the Capital Health—Edmonton & Area vice
Figure 2. Sticker for bookmark in medical chart.
Background was bright green. See Appendix 2 (available at
www.cjhp-online.ca/index.php/cjhp/issue/view/88/showToc)
for the colour version of this sticker.
©2005-2012 Alberta Health Services
J C P H – Vol. 65, no 4 – juillet–août 2012
295
0232_CJHP-July2012:sept.2008.qxd 8/7/12 7:23 AM Page 296
Figure 3. Self-adhesive sticker. Background was
bright green. See Appendix 3 (available at www.cjhponline.ca/index.php/cjhp/issue/view/88/showToc) for the
colour version of this sticker.
©2005-2012 Alberta Health Services
president of medical affairs and the University of Alberta dean
of medicine were sent to each physician, medical resident, and
undergraduate medical student in Capital Health—Edmonton
& Area. Internal communication documents were distributed
widely among nursing and pharmacy staff and dietitians.
The stickers for medical chart bookmarks (Figure 2) were
created to serve as a visual reminder to prescribers, encouraging
them to avoid using the prohibited abbreviations and dose
designations. One of these stickers was placed permanently in
a standard position in each patient’s chart. For inpatient units,
the bookmark sticker was placed on the plastic page divider of
the chart, so that when the chart was opened, the sticker would
appear to the left of the current patient care orders. For outpatient units and other areas that did not use a binder for patient
charts (such as clinics and the emergency department), the
bookmark sticker was placed in or on an area of the unit’s
choosing, to serve as a reminder to prescribers when writing
patient care orders. Enough bookmark stickers were provided
to ensure availability of one for each chart on each patient care
unit. The bookmark stickers were coated, such that they would
remain legible when charts were wiped down for infection
control purposes.
Small self-adhesive notes, preprinted with the term
“Prohibited Abbreviation” and an arrow (Figure 3), were
intended for use by anyone who noticed a prohibited abbreviation
or dose designation while processing a medication or TPN
order (handwritten or preprinted). The removable sticky note
was placed directly on the order within the chart, with the
arrow pointing to the prohibited abbreviation. The intent was
to provide a nonconfrontational, nonpermanent means of
notifying the prescriber that a prohibited abbreviation had been
used and as a reminder to avoid its use when writing future
orders. The prescriber could subsequently remove the sticky
note. The tool kits distributed to each patient care unit had
several pads of these custom-printed self-adhesive notes.
The stickers for chart bookmarks and the self-adhesive
notes were available for use when the list of prohibited abbreviations was implemented on October 1, 2005.
In-service education included delivery of more than 80
face-to-face presentations by members of the working group,
targeting mainly medical and nursing staff across the region.
Each presentation illustrated the risks to patient safety associated
296
C J H P – Vol. 65, No. 4 – July–August 2012
with the prohibited abbreviations and dose designations and
featured examples of prohibited abbreviations and how they
could be misinterpreted. All in-service presentations were
completed by September 30, 2005, before implementation of
the list of prohibited abbreviations.
RESULTS
During the 4-year evaluation period, at 4 specific time
points, a total of 26 202 medication orders were reviewed for
the presence of prohibited abbreviations. For each of these
audits, as well as the baseline audit, all medication orders
received on 1 day from 3 of the largest sites in Capital Health—
Edmonton & Area were reviewed.
The first set of data was collected in January 2005, to
measure baseline compliance with the established list of
prohibited abbreviations and dose designations. This baseline
audit revealed that 22.2% of medication orders (range
20%–23% for the 3 sites) involved the use of prohibited
abbreviations or designations (Table 2). The first compliance
audit, 3 months after completion of the intensive education
effort (December 2005), showed a reduction in the use of
prohibited abbreviations from the baseline value of 22.2%
to 13.7%. Subsequent compliance audits showed further
decreases in the use of prohibited abbreviations and designations, with an overall reduction of 64.4% from baseline over
the 4-year period, even as the number of orders audited
increased (Table 2).
Also included in the first compliance audit was 1 week’s
worth of TPN orders (n = 180) from the same 3 acute care sites.
By the time of the first compliance audit, in December 2005,
there was a 98.5% decrease (from 36.8% to 0.6%) in the use of
prohibited abbreviations (Table 3). Given these results and the
focused education that was provided to a relatively small
number of dieticians, TPN orders were not included in
subsequent audits.
Over the 4-year evaluation period, the overall reduction in
the use of prohibited abbreviations on medication and TPN
orders was 81.5%. Use of the prohibited abbreviations and dose
designations on the short list (Table 1) declined from baseline
for all but “trailing zero” (Table 4). Notably, the percentage of
audited orders with “QD” (or “qd”) decreased from 14.3% at
baseline to 1% at the end of the evaluation period. Use of drug
name abbreviations decreased from 5.2% to 4.3%.
DISCUSSION
The provision of quality patient care is directly dependent
upon optimal communication among health care providers.3
In this study, the baseline 1-day audit revealed that 917
orders from 3 sites contained one or more of the prohibited
abbreviations listed in Table 1. Assuming roughly 300
J C P H – Vol. 65, no 4 – juillet–août 2012
This single copy is for your personal, non-commercial use only.
For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact CJHP at cjhpedit@cshp.ca
Table 2. Results of Compliance Audits for All Medication Orders from 3 Acute Care Sites
over a 4-Year Period
Dangerous Abbreviations
Date of Audit
Total No. of Orders
No. (%) of Orders
Most Common
January 2005*
4 135
917 (22.2)
QD or qd
December 2005
6 184
846 (13.7)
Drug name and QD
June 2006
6 277
653 (10.4)
Drug name and QD
January 2008
6 818
615 (9.0)
Drug name and QD
January 2009
6 923
546 (7.9)
Drug name
Total
30 337
3 577 (11.8)
*Baseline data collected in January 2005, followed by educational presentations and distribution of tool
kits before implementation of list in October 2005.
Table 3. Results of Baseline and Compliance Audits for Total Parenteral Nutrition (TPN)
Orders at 3 Acute Care Sites
Dangerous Abbreviations
Month of Audit
Total No. of TPN Orders
No. (%) of Orders
Most Common
January 2005*
212
78 (36.8)
Trailing zero
December 2005
180
1 (0.6)
QD
Total
392
79 (20.2)
*Baseline data collected in January 2005, followed by educational presentations and distribution of tool
kits before implementation of list in October 2005.
Table 4. Use of Prohibited Abbreviations Before and After Implementation
Prohibited Abbreviation
IU
U or u
QD or qd
QOD or qod
Drug name
Trailing zero
No leading zero
Date; No. (%) of Orders with Abbreviation
January 2005
January 2009
(n = 4135)
(n = 6900)
12 (0.3)
14 (0.2)
86 (2.1)
121 (1.8)
590 (14.3)
71 (1.0)
3 (0.1)
0 (0)
213 (5.2)
296 (4.3)
10 (0.2)
35 (0.5)
3 (0.1)
9 (0.1)
noncompliant orders per day per site, enforcement (either by
calling each prescriber to seek clarification or refusing to
process the order until the prescriber wrote out the abbreviation
in full) would have disrupted patient care and caused a breakdown in relationships among medical, nursing, and pharmacy
staff. It should be noted, however, that during this initiative,
nursing and pharmacy staff did clarify orders with abbreviations if they felt it was necessary.
Over the study period, intensive, targeted, and wellreceived education, along with reminder tools, reduced the
incidence of prohibited abbreviations in medication and TPN
orders by 64.4% and 98.5%, respectively. The overall reduction
in the use of prohibited abbreviations was 81.5%, which far
exceeded the goal of 75%. This success was thought to be largely
attributable to the reminder tools. In particular, the bookmark
stickers for patients’ charts served as reminders to prescribers
before and during order-writing. Anecdotal reports indicated
that the self-adhesive notes were an effective yet nonconfrontational means of reminding prescribers to avoid a prohibited
abbreviation when writing the next order. Relationships among
clinicians were preserved, and patients were not put at further
risk by slowing or stopping the processing of orders.
Frequency of use decreased for all prohibited abbreviations
and dose designations except the trailing zero and no leading
zero. Even though use of both of these dose designations
increased over the study period, their overall use remained very
low (< 1%). The use of “QD” or “qd” showed the greatest decrease over time. This result was impressive, given that “QD” (or “qd”) was the most common among all of the prohibited abbreviations in the baseline audit. Also impressive was the consistent reduction in use of prohibited abbreviations over the 4-year period. Regular communication throughout the evaluation period involved sharing audit results with the Drugs and Therapeutics Committee and the Medical Advisory Council after each audit and including a one-line congratulatory note on staff members’ pay cheques following 2 of the 4 audits. There were no formal continuing education sessions after implementation of the list in October 2005, although all C J H P – Vol. 65, No. 4 – July–August 2012 J C P H – Vol. 65, no 4 – juillet–août 2012 297 This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact CJHP at cjhpedit@cshp.ca Table 5. Frequency of Orders in Final Audit (January 2009) that Contained Any of the 20 Error-Prone Drug Name Abbreviations Identified by Institution for Safe Medication Practices4 Abbreviation ARA A HCl HCTZ MgSO4 T3 TAC Nitro Drip PCA AZT CPZ DPT DTO HCT MS, MSO4 MTX PTU TNK ZnSO4 Norflox IV Vanc 298 Intended Meaning Mistaken As Vidarabine Cytarabine (ARA C) Hydrochloric acid or hydrochloride Potassium chloride Hydrochlorothiazide Hydrocortisone Magnesium sulphate Morphine sulphate Tylenol with codeine no. 3 Liothyronine Triamcinolone Tetracaine, adrenaline, cocaine Nitroglycerin infusion Sodium nitroprusside infusion Procainamide Patient-controlled anesthesia Zidovudine Azathioprine or aztreonam Prochlorperazine Chlorpromazine Demerol–phermegan–thorazine Diphtheria–pertussis–tetanus vaccine Diluted tincture of opium Tincture of opium Hydrocortisone Hydrochlorothiazide Morphine sulphate Magnesium sulphate Methotrexate Mitoxantrone Propylthioruacil Mercaptopurine TNKase TPA Zinc sulphate Morphine sulphate Norfloxacin Norflex Intravenous vancomycin Invanz No. (%) of All Abbreviations (n = 83) 1 (1) 1 (1) 9 (11) 25 (30) 5 (6) 1 (1) 1 (1) 40 (48) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) of the information and educational materials remained posted online (on the institutional intranet) for staff and physicians. The drug name abbreviations appearing on medication orders from the fourth compliance audit (January 2009) were further analyzed to determine if they included any of the 20 error-prone drug name abbreviations that ISMP has deemed unsafe4 (Table 5). Of the 296 drug name abbreviations noted during the audit, less than one-third (83 or 28%) represented abbreviations included in the ISMP list of error-prone drug name abbreviations (Table 5), and they accounted for only 8 of the 20 abbreviations in this list. The biggest contributor to these numbers was the abbreviation “PCA”, which is often used to abbreviate procainamide. In the chart audits for Capital Health—Edmonton & Area, however, PCA was exclusively used to abbreviate “patient controlled analgesia”. According to Accreditation Canada, neither use of this abbreviation is acceptable. The remaining 12 of the 20 error-prone drug name abbreviations identified by ISMP were not found in the orders audited from Capital Health—Edmonton & Area. Conversely, the ISMP list did not include 213 other drug abbreviations found in the audit. The most common of these were “pip/tazo” and “KCl”. Neither of these has so far been reported to have contributed to morbidity or mortality from misinterpretation, so it is probably unnecessary to recommend that these abbreviations be added to the ISMP list. In anticipation of Accreditation Canada’s Required Organizational Practice to adopt the ISMP “Do Not Use” abbreviations list, the results of the latest audit (in January 2009) were also further analyzed to determine the frequency of the additional 9 dangerous abbreviations and dose designations that would need to be prohibited in Capital Health—Edmonton & Area. No communication or education strategies were applied before this additional analysis. The 9 abbreviations and designations (“µg”, “OD”, “OS”, “OU”, “cc”, “D/C”, “@”, “>”, and “